annual telephone interview - health abcannual telephone interview since we last spoke to you about...

HABCID

H

HABC Enrollment ID # Acrostic

ACROS

Date Visit Completed Staff ID #

Y13TISTID

ANNUAL TELEPHONE INTERVIEW

Y13INTDATE

/ /YearDayMonth

CONTAC

Year 12

Year 13

Year 14

Year 15

Year of Annual Interview:

Annual Telephone InterviewVersion 4.0, 5/27/08

What is your...?

First Name Last NameM.I.

TBFNM TBLNM

Annual Telephone Interview

In general, how would you say your health is? Would you say it is. . .

Y13HSTAT

Excellent

Very good

Good

Fair

Poor

Don't know

Refused

(Examiner Note: Read response options.)

Since we last spoke to you about [# months since last contact] months ago, did you stay in bed all ormost of the day because of an illness or injury? Please include days that you were a patient in ahospital.

Y13BED12Yes No Don't know Refused

About how many days did you stay in bed all or most of the day because of an illness or injury?Please include days that you were a patient in a hospital.(Examiner Note: If necessary, probe - "If you are unsure, please make your best guess.")

days

Since we last spoke to you about [# months since last contact] months ago, did you cut down on the thingsyou usually do, such as going to work or working around the house, because of an illness or injury?Please include days in bed.

Y13CUT12Yes No Don't know Refused

How many days did you cut down on the things you usually do because of illness or injury?Please include days in bed.(Examiner Note: If necessary, probe - "If you are unsure, please make your best guess.")

days

1.

2.

3.

Y13BEDDAY

1

2

3

4

5

8

7

1 8 70

1 0 8 7

Y13CUTDAY

HABCID

H

ANNUAL TELEPHONE INTERVIEW

ACROS

Acrostic Year of Annual InterviewHABC Enrollment ID #

CONTAC

Year 11 Year 12 Year 13Year 14 Year 15

Date of last regularlyscheduled contact:

(Examiner Note: Refer to Data from Prior Visits Report. Please also record this date onthe top of page 20. If participant agrees to only partial interview, ask questions first.)

NOT COLLECTED

/ /Month Day Year

= Priority questions



Since we last spoke to you about [# months since last contact] months ago,did you stay overnight as a patient in a nursing home or rehabilitation center?

Since we last spoke to you about [# months since last contact] months ago, did you receivecare at home from a visiting nurse, home health aide, or nurse's aide?

MEDICAL STATUS

Y13MCNHYes No Don't know Refused

Y13MCVNYes No Don't know Refused

4.

5.

1 0 8 7

1 0 8 7

HABCID

HACROS


CONTAC



Y13MNRSArthritis

Back pain

Balance problems/unsteadiness on feet

Cancer

Chest pain/discomfort

Circulatory problems

Diabetes

Fatigue/tiredness (no specific disease)

Fall

Foot/ankle pain

Heart disease

High blood pressure/hypertension

Hip fracture

Injury

Joint pain

Leg pain

Lung disease

Old age

Osteoporosis

Shortness of breath

Stroke

Other symptom

Multiple conditions/symptoms

Don't know

Because of a health or physical problem, do you have any difficulty walking a quarter of a mile,that is about 2 or 3 blocks?(Examiner Note: If the participant responds "Don't do," probe to determine whether this is becauseof a health or physical problem. If the participant doesn't walk because of a health or physicalproblem, mark "Yes." If the participant doesn't walk for other reasons, mark "Don't do.")

How much difficulty do you have?(Examiner Note: Read response options.)

Y13DWQMDFA little difficulty Some difficulty A lot of difficulty Or are you unable to do it Don't know

What is the main reason that you have difficulty? Is it because of arthritis, shortness of breath,heart disease, or some other reason?(Examiner Note: Do NOT read response options. If "some other reason," probe forresponse. Mark only ONE answer.)

(including angina, congestive heart failure, etc)

(asthma, chronic bronchitis, emphysema, etc)

(no mention of a specific condition)

(Please specify: )

unable to determine MAIN reason

Go to Question #6d

a.

b.

(Please specify: )

Go to Question #7

PHYSICAL FUNCTION

c. Do you have any difficulty walking across a small room?

Y13DWSMRMYes No Don't know Refused

Go to Question #7

6.

1 0 8 7 9

1 2 3 4 8

1

2

3

4

5

6

7

8

9

23

10

11

12

13

14

24

15

16

17

18

19

20

21

22

1 0 8 7

HABCID

HACROS


CONTAC


Y13DWQMYNYes No Don't know Refused Don't do


How easy is it for you to walk a quarter of a mile?(Examiner Note: Read response options.)

Y13DWQMEZ

Very easy

Somewhat easy

Or not that easy

Don't know/don't do

Because of a health or physical problem, do you have any difficulty walking a distance ofone mile, that is about 8 to 12 blocks?

Yes

No

Don't know/don't do

How easy is it for you to walk one mile?(Examiner Note: Read response options.)

Y13DW1MEZ

Very easy

Somewhat easy

Or not that easy

Don't know/don't do

6d.

6e.

6f.

Go to Question #7

Go to Question #6f

Go to Question #6f

PHYSICAL FUNCTION

1

2

3

8

1

0

8

1

2

3

8

HABCID

HAcrostic Year of Annual InterviewHABC Enrollment ID #


CONTACACROS

Y13DW1MYN


Go to Question #7c

Because of a health or physical problem, do you have any difficulty walking up 10 steps,that is about 1 flight, without resting?(Examiner Note: If the participant responds "Don't do," probe to determine whether this isbecause of a health or physical problem. If the participant doesn't walk up 10 steps because ofa health or physical problem, mark "Yes." If the participant doesn't walk up steps for otherreasons, such as there are simply no steps in the area, mark "Don't do.")

How much difficulty do you have?(Examiner Note: Read response options.)Y13DIF

A little difficulty Some difficulty A lot of difficulty Or are you unable to do it Don't know

What is the main reason that you have difficulty? Is it because of arthritis, shortness of breath,heart disease, or some other reason?(Examiner Note: Do NOT read response options. If "some other reason,"probe for response. Mark only ONE answer.)

a.

b.

Go to Question #8

Go to Question #8

PHYSICAL FUNCTION

Y13MNRS2Arthritis

Back pain


Cancer



Diabetes


Fall

Foot/ankle pain

Heart disease


Hip fracture

Injury

Joint pain

Leg pain

Lung disease

Old age

Osteoporosis

Shortness of breath

Stroke

Other symptom


Don't know(including angina, congestive heart failure, etc)



(Please specify: )


(Please specify: )

7.

1 0 8 7 9

1 2 3 4 8

1

2

3

4

5

6

7

8

9

23

10

11

12

13

14

24

15

16

17

19

18

20

21

22

HABCID



ACROS CONTAC

Y13DW10YNYes No Don't know Refused Don't do


7c.

7d.

7e.

How easy is it for you to walk up 10 steps without resting?(Examiner Note: Read response options.)

Y13DW10EZ

Very easy

Somewhat easy

Or not that easy

Don't know/don't do

Because of a health or physical problem, do you have any difficulty walking up 20 steps,that is about 2 flights, without resting?

Yes

No

Don't know/don't do


Y13DW20EZ

Very easy

Somewhat easy

Or not that easy

Don't know/don't do

Go to Question #8

Go to Question #7e

PHYSICAL FUNCTION

Go to Question #7e

1

2

3

8

1

0

8

1

2

3

8

HABCID



ACROS CONTAC

Y13DW20YN


Do you have to use a cane, walker, crutches, or other special equipment to help you get around?

Do you have any difficulty bathing or showering?

Does someone usually help you bathe or shower?

Y13BATHRHYes No Don't know

Y13BATHYNYes No Don't know Refused

Because of a health or physical problem, do you have any difficulty getting in and out of bed or chairs?

Y13DIOYNYes No Don't know Refused

Does someone usually help you get in and out of bed or chairs?

Y13DIORHYYes No Don't know

Do you have any difficulty dressing?

Does someone usually help you to dress?

Y13DDYNYes No Don't know Refused

Y13EQUIPYes No Don't know Refused

PHYSICAL FUNCTION

Because of a health or physical problem, do you have any difficulty standing up from a chairwithout using your arms?


Y13DSTAMT

A little difficulty

Some difficulty

A lot of difficulty

Or are you unable to do it

Don't know

How easy is it for you to stand up from a chair withoutusing your arms?(Examiner Note: Read response options.)

Y13EZSTA

Very easy

Somewhat easy

Or not that easy

Don't know

Y13DIFSTAYes No Don't know Refused

Y13DDRHYNYes No Don't know

8.

9.

10.

11.

12.

1 0 8 7

1 0 8 7

1 0 8 7

1 0 8 7

1 0 8 7

1

2

3

4

8

1

2

3

8

1 0 8

1 0 8

1 0 8

HABCID



ACROS CONTAC


Do you have any difficulty stooping, crouching or kneeling?(Examiner Note: "Difficulty" refers to difficulty getting down AND/OR getting back up.)

Y13DSCKAM

A little difficulty

Some difficulty

A lot of difficulty


Don't know


PHYSICAL FUNCTION

Yes No Don't know Refused

Do you have any difficulty raising your arms up over your head?

Do you have any difficulty using your fingers to grasp or handle?



Y13DARMAM

A little difficulty

Some difficulty

A lot of difficulty


Don't know



Y13DIFNAM

A little difficulty

Some difficulty

A lot of difficulty


Don't know

13.

14.

15.

1 0 8 7

1 0 8 7

1 0 8 7

1

2

3

8

4

8

4

3

2

1

8

4

3

2

1

HABCID



ACROS CONTAC

Y13DIFSCK

Y13DIFARM

Y13DIFFN


Because of a health or physical problem, do you have any difficulty lifting or carrying somethingweighing 10 pounds, for example a small bag of groceries or an infant?

How much difficulty do you have?(Examiner Note:Read response options.)

How easy is it for you to lift or carry somethingweighing 10 pounds?(Examiner Note: Read response options.)

Y13D10AMT

A little difficulty

Some difficulty

A lot of difficulty

Or are you unable

Don't know

Y13EZ10LB

Very easy

Somewhat easy

Or not that easy

Don't know

Do you have any difficulty lifting or carrying somethingweighing 20 pounds, for example, a large full bag ofgroceries?


Y13EZ20LB

Very easy

Somewhat easy

Or not that easy

Don't know

to do it

Go to Question #17


Y13D20LBSYes No Don't know

16.

PHYSICAL FUNCTION

1 0 8 7

1

2

3

4

8

1

2

3

8

8

3

2

1

1 0 8

HABCID



ACROS CONTAC

Y13DIF10


Did you do heavy or major chores like scrubbing windows or walls, vacuuming, orcleaning gutters; home maintenance activities like painting; gardening or yardwork;or anything like these activities, at least 10 times, in the past 12 months?

a. In the past 7 days, did you do heavy chores or home maintenance activities?

Go to Question #18

Go to Question #18

b. About how much time did you spend doing heavy chores or homemaintenance activities in the past 7 days (not counting rest periods)?(Examiner Note: If less than 1 hour, record number of minutes.)

Y13HC12MOYes No Don't know Refused

HCHRS HCMINSHours Minutes

Y13HCDKDon't know

Y13HC7DAYYes No Don't know

PHYSICAL ACTIVITY AND EXERCISE

17.

1 0 8 7

801

-1

HABCID



ACROS CONTAC

Y13HCTIM


Did you walk for exercise, or walk to work, the store, or church, or walk the dog,at least 10 times, in the past 12 months?

In the past 7 days, did you go walking?

Go to Question #19

What is the main reason you didnot go walking in the past 7 days?

Y13EWREAS

Bad weather

Not enough time

Injury

Health problems

Lost interest

Felt unsafe

Not necessary

Other

Don't know

How many times did you go walking in the past 7 days?

timesAbout how much time, on average, did you spendwalking each time you walked (excluding rest periods)?(Examiner Note: If less than 1 hour, record numberof minutes.)

When you walk, do you usually walk at a brisk pace(as fast as you can), a moderate pace, or at a leisurelystroll? Y13EWPACE

Brisk Moderate Stroll Don't know

Y13EW7DAYYes No

Y13EW12MOYes No Don't know Refused

a.

b.

c.

EWHRSEWMINS

Hours Minutes

Y13EWTMDKDon't know

Y13EWTDKDon't know


Did you walk up a flight of stairs (a flight is about 10 steps), at least 10 times, in the past 12 months?

a. In the past 7 days, did you walk up a flight of stairs?

b. About how many flights did you walk up in the past 7 days?If you are unsure, please make your best guess.

flights

About how many of these flights did you walk up carrying a small loadlike laundry, groceries, or an infant?

c.

flights

Go to Question #20

Go to Question #20

Y13FS12MOYes No Don't know Refused

Y13FSNUMDDon't know

Y13FSLODKDon't know

Y13FS7DAYYes No Don't know

18.

19.

1 0 8 7

1 0

-1

-1

-1

-1

1

2

3

4

5

6

7

8

9

1 0 8

1 2 3 8

Y13EWTIME

Y13FSNUM

Y13FSLOAD

7801

HABC Enrollment ID #

HABCID

HAcrostic Year of Annual Interview


ACROS CONTAC

Y13EWTIM


Did you do any high intensity exercise, such as bicycling, swimming, jogging, racquetsports or using a stair-stepping, rowing or cross country ski machine or exercycle,at least 10 times, in the past 12 months?

In the past 7 days, did you do high intensity exercise?

Go to Question #21

Y13HI7DAYYes No

Y13HINDEX

Bad weather

Not enough time

Injury

Health problems

Lost interest

Felt unsafe

Not necessary

Other

Don't know

What is the main reason you have not done anyhigh intensity exercise in the past 7 days?

What activity(ies) did you do?

Y13HIABEBicycling/exercycle

Y13HIASWMSwimming

Y13HIAJOGJogging

Y13HIAAERAerobics

Y13HIARSRacquet sports

Y13HIAROWRowing machine

Y13HIASKICross country ski machine

Y13HIAOTHOther

Y13HIASSStair-stepping

In the past 7 days, about how much time didyou spend doing (first activity named byparticipant)?(Examiner Note: If less than 1 hour,record number of minutes.)

Mark all that apply.

Y13HI12MOYes No Don't know Refused


a.

b.

(Please specify):

HIA

1HR

HIA

1MN

Hours MinutesY13HIA1DKDon't know

20.

-1

-1

-1-1

-1

-1

-1

-1

-1

1

2

3

4

5

6

7

8

9

-1

1 0 8 7

1 0


HABCID



ACROS CONTAC

Y13H1TIME


Did you do any moderate intensity exercise, such as golf, bowling, dancing, skating,bocce, table tennis, hunting, sailing or fishing, at least 10 times, in the past 12 months?

In the past 7 days, did you do moderate intensity exercise?

Y13MI7DAYYes No

What is the main reason you havenot done any moderate intensityexercise in the past 7 days?

Y13MINDEX

Bad weather

Not enough time

Injury

Health problems

Lost interest

Felt unsafe

Not necessary

Other

Don't know


Y13MIGOLFGolf

Y13MIBOWLBowling

Y13MIDANCDancing

Y13MISKATSkating

Y13MIBOCCBocce

Y13MITENNTable tennis

Y13MIOT1Other

Y13MIPOOLBilliards/pool

Y13MIHUNTHunting

Y13MIBOATSailing/boating

Y13MIFISHFishing

In the past 7 days, about how much time didyou spend doing (first activity named byparticipant)?(Examiner Note: If less than 1 hour, recordnumber of minutes.)

Mark all that apply.

Go to Question #22

(Please specify):

MIA

1HR

MIA

1MN

Hours Minutes


Y13MI12MOYes No Don't know Refused

Y13MIA1DKDon't know

b.

a.

21.

1 0 8 7

1 0

1

2

3

4

5

6

7

8

9

-1

-1

-1

-1

-1

-1

-1

-1

-1

-1

-1

-1

HABCID



ACROS CONTAC

Y13M1TIME


Do you currently work for pay, either at a regular job, consulting, or doing odd jobs?

Y13VWCURJYes No Don't know Refused

WORK, VOLUNTEER, AND CAREGIVING ACTIVITIES

22.

Do you currently do any volunteer work?

Y13VWCURVYes No Don't know Refused

23.

24. Do you currently provide any regular care or assistance to a child or a disabled or sick adult?

Y13VWCURAYes No Don't know Refused

1 0 8 7

1 0 8 7

1 0 8 7

HABCID



ACROS CONTAC


1

2

3

4

5

8

7

1 0 8 7

-1

APPETITE AND WEIGHT CHANGE

In general, would you say that your appetite or desire to eat has been. . . ?(Examiner Note: Read response options.)

Y13APPET

Very good

Good

Moderate

Poor

Very poor

Don't know

Refused

Now I have some questions about your appetite.25.

Y13TRYLS2Yes No Don't know Refused

At the present time, are you trying to lose weight?26.

SMOKING HABITS

On the average, about how many cigarettes a day do you smoke?

Do you currently smoke cigarettes?

cigarettes per day

27.Y13SMOKEYes No Don't know Refused

On average, about how many cigarettes a day do you smoke?

Y13SMOKEDKDon't know

HABCID


25A. Because of a health or physical problem, do you have any difficulty preparing meals?

25B. Because of a health or physical problem, do you have any difficulty shopping for food?

25C. How much do you currently weigh?(Examiner Note: If necessary, probe - "If you are unsure, please make your best guess.")

pounds Y13LBS2Don't know/don't remember Refused

Y13DFPREPYes No Does not do Don't know Refused

Y13DFSHOPYes No Does not do Don't know Refused


1 0 8 7

9

7801

7801

Y13WTLBS

Y13SMOKAV-1

8 7

9

ACROS CONTAC


28.

MEDICAL CONDITIONS

Now I'm going to ask you about some medical problems that you might have had in the past 12 months.

Hypertension or high blood pressure? We are specifically interested in hearing abouthypertension or high blood pressure that was diagnosed for the first time in the past 12 months.

Y13HCHBPYes No Don't know Refused

Diabetes or sugar diabetes? Again, we are specifically interested in hearing aboutdiabetes that was diagnosed for the first time in the past 12 months.

Y13SGDIABYes No Don't know Refused

In the past 12 months, have you fallen and landed on the floor or ground?

How many times have you fallen in the past 12 months?If you are unsure, please make your best guess.

Go to Question #31

Y13AJFALLYes No Don't know Refused

Y13AJFNUM

One

Two or three

Four or five

Six or more

Don't know

In the past 12 months, has a doctor told you that you had...?

29.

30.

1 0 8 7

7801

7801

1

2

4

6

8


HABCID



ACROS CONTAC




Go to Question #31

Y136MFALLYes No Don't know Refused

Y136MFNUM

OneTwo or threeFour or fiveSix or moreDon't know

a

HABCID

H


i.

Were you injured in any of your falls?

Y13INJFALYes No Don't know

ii.

Go to Question #31

iii. Did you seek medical treatment after any of your falls?

Y13TRTFALYes No Don't know

iv. Were you hospitalized after any of your falls?

Y13HOSFALYes No Don't know

v. Have you been told by a doctor that you broke or fractured a bone(s)because of any of your falls?

Y13BBNFALYes No Don't know

MEDICAL CONDITIONS


30A.Now, please think about the past 6 months.

1 0 8 7

1

2468

1 0 8

1 0 8

1 0 8

1 0 8

(Examiner Note: Page 18 [Questions #33 - #37] have been removedfrom the Annual Telephone Interview.)

Are you troubled by shortness of breath when hurrying on a level surface or walking up a slight hill?

Y13LCSBUPYes No Don't know Refused

Do you ever have to stop for breath when walking at your own pace on a level surface?

Y13LCSBLSYes No Don't know Refused

31.

32.

7801

1 0 8 7

ACROS CONTAC


Has a doctor ever told you that you had any of the following...?

Emphysema?

Chronic obstructive pulmonary disease or COPD?

a.

b.

c. Chronic bronchitis?

Do you still have chronic bronchitis?

Y13LCSHCBYes No Don't know

Y13LCEMPHYes No Don't know Refused

Y13LCCOPDYes No Don't know Refused

Y13LCCHBRYes No Don't know Refused

38.

MEDICAL CONDITIONS

71 0 8

71 0 8

71 0 8

1 0 8

HABCID



(Examiner Note: Page 18 [Questions #33 - #37] have been removedfrom the Annual Telephone Interview.)

ACROS CONTAC


39.

MEDICAL CONDITIONS IN PAST 6 MONTHSNow I'm going to ask you about any medical problems you might have had since we last spoke to youabout [# months since last contact] months ago, which was on

Since we last spoke to you about [# months since last contact] months ago, has a doctor toldyou that you had a

Y13HCHAMIYes No Don't know Refused

Were you hospitalized overnight for this problem?

Complete a Health ABC Event Form, Section I,for each overnight hospitalization. Record reference #'s below:

a.

b.

c.REF39C

REF39B

REF39A

Y13HOSMIYes No

Go to Question #40

Since we last spoke to you about [# months since last contact] months ago,has a doctor told you that you had congestive heart failure?

Y13CHFYes No Don't know Refused



a.

b.

c. REF40C

REF40B

REF40A

Y13HOSMI3Yes No

Go to Question #41

YearDayMonth

40.

71 0 8

71 0 8

1 0

1 0

HABCID



ACROS CONTAC

NOT DATA


Since we last spoke to you about [# months since last contact] months ago,has a doctor told you that you had a stroke, mini-stroke, or TIA ?

Y13HCCVAYes No Don't know Refused



a.

b.

c. REF41C

REF41B

REF41A

Y13HOSMI2Yes No

Go to Question #42

41.

MEDICAL CONDITIONS IN PAST 6 MONTHS

Since we last spoke to you about [# months since last contact] months ago, has a doctor told you thatyou had cancer? We are specifically interested in hearing about a cancer that your doctor diagnosedfor the first time since we last spoke to you.

Y13CHMGMTYes No Don't know Refused

a.

b.

c.REF42C

REF42B

REF42A

Complete a Health ABC Event Form, Section II, for each event.Record reference #'s below:

42.

71 0 8

71 0 8

1 0


HABCID



ACROS CONTAC


b.

Since we last spoke to you about [# months since last contact] months ago,has a doctor told you that you had pneumonia?

Y13LCPNEUYes No Don't know Refused


a.

c.REF43C

REF43B

REF43A

MEDICAL CONDITIONS IN PAST 6 MONTHS43.

Since we last spoke to you about [# months since last contact] months ago,have you been told by a doctor that you broke or fractured a bone(s)?

Y13OSBR45Yes No Don't know Refused

a.

b.

c.REF44C

REF44B

REF44A


44.

1 0 8 7

1 0 8 7

HABCID



ACROS CONTAC


MEDICAL CONDITIONS IN PAST 6 MONTHS45. Were you hospitalized overnight for any other reasons since we last spoke to you about

[# months since last contact] months ago?

Y13HOSP12Yes No Don't know Refused

Have you had any same day outpatient surgery since we last spoke to you about[# months since last contact] months ago?

Y13OUTPAYes No Don't know Refused

Was it for. . .?A procedure to opena blocked artery

Y13BLART

Yes

No

Don't know

Gall bladder surgery

Cataract surgery

TURP (MEN ONLY)(transurethral resectionof prostate)

a.

b.

c.

d.

a. b. c.REF45B

REF45D

REF45A

Complete a Health ABC Event Form, Section I, for each event.Record reference #'s and reason for hospitalization below.

REF45E

REF45C

REF45Fd. e. f.

Reason for hospitalization: Reason for hospitalization: Reason for hospitalization:


Complete a Health ABC Event Form,Section III. Record reference #:

Y13GALLBL

Yes

No

Don't know

Y13CATAR

Yes

No

Don't know

Y13TURP

Yes

No

Don't know

REF46A

Reference #

46.

1 0 8 7

1 0 8 7

1

08

1

08

80

1

80

1


HABCID



ACROS CONTAC


MEDICAL CONDITIONS AND FATIGUE

Please describe for what:

Is there any other illness or condition for which you see a doctor or other health care professional?

Go to Question #48

Y13OTILLYes No Don't know Refused

47.

Energy levelY13ELEVRF

Don't know Refused

48.

1 0 8 7

Y13ELEV 8 7


HABCID



Please describe your usual energy level in the past month, where 0 is no energy and 10 isthe most energy that you have ever had.

48A. In the past month, on the average, have you been feeling unusually tired during the day?

Have you been feeling unusually tired...?(Examiner Note: Read response options.)

Y13ELOFTN

All of the time

Most of the time

Some of the time

Don't know

Refused

Y13ELTIREYes No Don't know Refused1 0 8 7

1

2

3

8

7

ACROS CONTAC


EYESIGHT AND DRIVING

Now I would like to ask you some questions about your eyesight.

At the present time, would you say your eyesight (with glasses or contact lenses, if youwear them) is excellent, good, fair, poor, or very poor or are you completely blind?

Y13ESQUAL

Excellent

Good

Fair

Poor

Very poor

Completely blind

Don't know

Refused

49.

50. Now, I'd like to ask about driving a car. Are you currently driving, at least once in a while?Y13ESCAR

Yes No, I never drove No, I am no longer driving Don't know Refused

When did you stop driving?

Did you stop driving because of your eyesight?

Y13ESSITEYes No Don't know

Y13ESSTOP

Less than 6 months ago

6-12 months ago

More than 12 months ago

Don't know

a.

b.

1

2

3

4

5

6

8

7

1 0 2 8 7

1

2

3

8

1 0 8

HABCID



Examiner Note: Questions #51 and #52 have been removed from the Annual Telephone Interview.

(Examiner Note: Pages 26 and 27 have been removed

from the Annual Telephone Interview.)

ACROS CONTAC


MARITAL STATUS AND HOUSEHOLD OCCUPANCY

Y13MARSTA

Married

Widowed

Divorced

Separated

Never married

Don't know

Refused

Y13SSOPRFParticipant lives alone

Don't know

Refused

Beside yourself, how many other people live in your household?

Other people in household

What is your marital status? Are you...?(Examiner Note: Read response options.)

53.

54.

1

2

3

4

5

8

7

Y13SSOPIH

1

8

7

HABCID



Page 28(Examiner Note: Pages 26 and 27 have been removed

from the Annual Telephone Interview.)

Examiner Note: Questions #51 and #52 have been removed from the Annual Telephone Interview.

ACROS CONTAC


SOCIAL NETWORK AND SUPPORTIn a typical week, how often do you get together with friends or neighbors? Would you say...(Examiner Note: Read response options.)

Y13SSFRNE

At least once a day

4 to 6 times per week


1 time per week

Less than once per week

Don't know

Refused

In a typical week, how often do you get together with your children or other relatives?Would you say...(Examiner Note: Read response options.)

Y13SSCHRE

At least once a day



1 time per week

Less than once per week

Don't know

Refused

55.

56.

Page 29

1

2

3

4

5

8

7

1

2

3

4

5

8

7

HABCID



ACROS CONTAC

Annual Telephone InterviewPage 30

HEALTH CARE/INSURANCE

Where do you usually go for health care or advice about health care?(Examiner Note: Read response options. Mark only ONE answer.)

Y13HCSRC

Private doctor's office (individual or group practice)

Public clinic such as a neighborhood health center

Health Maintenance Organization (HMO)

Hospital outpatient clinic

Emergency room

Other

Examiner Note: Please update the name, address, and telephonenumber of the doctor or place that the participant usually goes to forhealth care.

(Please specify:

(Examples: Health Maintenance Organization (e.g., Keystone,Cigna, UPMC Health Plan, Aetna, HealthAmerica, HealthSpring )

(Please specify:

)

)

Do you have a health insurance plan or other supplemental coverage which pays for avisit to a doctor?

Y13HCHIYes No Don't know Refused

What type of health insurance do you have?(Examiner Note: Please record all types below. If participant is unsure whether theyhave Part B Medicare, ask if you may look at their Medicare card.)

Health Choices; Health Pass, Tenn Care)

(Please specify: )

)(Please specify:

(Please specify: )

HealthAmerica, HealthSpring) (Please specify: )

Y13HCHI01 Part B Medicare

Y13HCHI02 Medicaid/public medical assistance (e.g., Family Care Network;

Y13HCHI03 Health Maintenance Organization (e.g., Keystone; Cigna; UPMC Health Plan; Aetna;

Y13HCHI04 Medi-Gap

Y13HCHI05 Private insurance

Y13HCHI06 Other

57.

58.

1

2

3

4

5

6

1 0 8 7

-1

-1

-1

-1

-1

-1



ACROS CONTACHABCID


Page 31

CURRENT ADDRESS AND TELEPHONE NUMBER

Is the address that we currently have correct?

The telephone number(s) that we currently have for you is (are):(Examiner Note: Please confirm that the telephone number(s) that you have for theparticipant are correct.)

Please tell me if these telephone number(s) are correct.

Examiner Note: Please update the telephone number(s) for the participant.

Are the telephone number(s) that we currently have correct?Yes No

Do you expect to move or have a different address in the next 6 months?

Examiner Note: Please record the new mailing address and telephone number, anddate the new address and telephone numbers are effective.


We would like to update all of your contact information this year. The address that we currently havelisted for you is:(Examiner Note: Please confirm that the address you have for the participant is correct.)

Please tell me if the information I have is still correct.

Examiner Note: Please update street address, city, state and zip code for theparticipant.

Yes No

59.

60.

61.




HABCID ACROS CONTACData on this pagewas collected forclinic use only


CONTACT INFORMATION62. You previously told us the name of someone who could provide information and answer

questions for you in the event that you were unable to answer for yourself. Please tell me if theinformation I have is still correct.(Examiner Note: Please confirm that the contact information for someone who couldprovide information and answer questions for the participant is correct.)

Is the contact information for someone who could provide information and answerquestions for the participant correct?

Yes No

Go to Question #63

Examiner Note: Please update the name, street address, city, state, zip code,and telephone number for someone who could provide information and answerquestions for the participant. Please determine whether this person is next ofkin or has power of attorney.

Has the participant identified their next of kin?(Examiner Note: Refer to the participant's chart.)


Go to Question #65Go to Question #64

Examiner Note: Please confirm that the contact information for the next of kin is correct.

You previously told us the name and address of your next of kin. Please tell me if theinformation I have is still correct.

Is the name and address of the next of kin correct?

Go to Question #65

Go to Question #65

Go to Question #65


Examiner Note: Please update the name, street address, city, state, zip code, andtelephone number, and how the person is related to the participant.

63.




HABCID ACROS CONTAC

Data on this pagewas collected forclinic use only


CONTACT INFORMATION64. Please tell me the name, address, and telephone number of your next of kin.

How is this person related to you?

Examiner Note: Please confirm that the contact information for the power of attorney iscorrect.

You previously told us the name and address of your power of attorney. Please tell me if theinformation I have is still correct.

Has the participant identified their power of attorney?(Examiner Note: Refer to the participant's chart.)

Go to Question #67

Is the name and address of the power of attorney correct?

Go to Question #66

Go to Question #67

Go to Question #67

Go to Question #67


Have you given anyone power of attorney?Yes No Don't know Refused

65.

66.





Examiner Note: Please record the name, street address, city, state, zip code, andtelephone number for the next of kin, and how the person is related to the participant.

Examiner Note: Please update the name, street address, city, state, zip code, and telephonenumber of the power of attorney, and how the person is related to the participant.

Examiner Note: Please update the name, street address, city, state, zip code, telephonenumber of the power of attorney, and how the person is related to the participant.

HABCID ACROS CONTACData on this pagewas collected forclinic use only


CONTACT INFORMATION67.

(Examiner Note: Please confirm that the contact information for two, friends, relatives, or aclergy person who do not live with the participant is correct.)

You previously told us the name, address, and telephone number of two friends, relatives, ora clergy person who do not live with you and who would know how to reach you in case you moveand we need to get in touch with you. These people did not have to be local people. Please tell meif the information I have is still correct.

Yes No

Go to Question #68

Is the contact information for the two close friends or relatives who do not live with the participantand who would know how to reach the participant in case they move correct?

Examiner Note: Please answer the following question based on your judgment of theparticipant's responses to this questionnaire.

On the whole, how reliable do you think the participant's responses to this questionnaire are?

Y13RELY

Very reliable

Fairly reliable

Not very reliable

Don't know

68.

Page 34

1

2

3

8

Examiner Note: Please update the name, street address, city, state, zip code, andtelephone number for two close friends, relatives, or clergy person. Please determinewhether this person is next of kin or has power of attorney.



Thank you very much for answering these questions. I enjoyed talking with you. Pleaseremember to call us if you are admitted to a hospital or nursing home for any reason so thatwe can better understand changes in your health. We would also like to hear from you ifyou move or if your mailing address changes. We will be calling you in about 6 monthsfrom now to find out how you've been doing.

HABCID ACROS CONTAC

HABC Enrollment ID # Acrostic Date Form Completed Staff ID #

ACROS YASTFID

Page 1


YearDayMonth

Type of Contact:

YACONTAC

Home (face-to-face interview)

Clinic (face-to-face interview)

Nursing home (face-to-face interview)

Telephone interview

Other (Please specify:

1.

=Semi-annualtelephone contactquestions

PROXY INTERVIEWHABCID

H

Page Link #

What is your relationship to (name of Health ABC participant)?

YAREL

Spouse or partner

Child

Family member (other than spouse or child)

Close friend

Health care provider

Other

Refused

(Please specify:

2. How often do you have contact with (him/her)?(Interviewer Note: Please mark only one answer.)

YACONFRQ

Live together

Daily

3 or more times a week

Less than 3 times a week

Don't know

Refused

Proxy Interview, Version 1.6, 6/3008

Interviewer Note: Ask all questions for annual contact. Ask only questions during semi-annual telephone contact.

)

Year of Contact:

(Please specify:

Go to Question #4

(but does not live together)

YADATE

/ /YearDayMonth

YADATES

/ /

)

)

1

2

3

4

5

6

7

1

2

3

4

8

7

YALINK

YARELOTH

VISITYear 11Year 11.5Year 12Year 12.5Year 13

Year 13.5Year 14Year 14.5Year 15Other

(Please specify )

Interviewer Note: This refersto the type of contact thePARTICIPANT would have had, notwhere the proxy was interviewed.

Since we last spoke to (name of Health ABC participant) about 6 months ago, did (he/she) stay inbed all or most of the day because of an illness or injury? Please include days that (he/she) was apatient in a hospital.

YABEDYes No Don't know Refused

About how many days did (he/she) stay in bed all or most of the day because of an illness or injury?Please include days that (he/she) was a patient in a hospital.(Interviewer Note: If necessary, probe - "If you are unsure, please make your best guess.")

days

Since we last spoke to (name of Health ABC participant) about 6 months ago, did (he/she)cut down on the things (he/she) usually did, such as going to work or working around the house,because of an illness or injury? Please include days in bed.

YACUT Yes No Don't know Refused

How many days did (he/she) cut down on the things (he/she) usually did because of illness or injury?Please include days in bed.(Interviewer Note: If necessary, probe - "If you are unsure, please make your best guess.")

days

4.

5.

3. What is the most frequent type of contact?

YACONTYP

Mostly in person

Mostly by phone

Both in person and by phone

Other

Don't know

Refused

(Please specify:

PROXY INTERVIEW

Since we last spoke to (name of Health ABC participant) about 6 months ago, did (he/she)stay overnight as a patient in a nursing home or rehabilitation center?

6.

Since we last spoke to (name of Health ABC participant) about 6 months ago, did (he/she)receive care at home from a visiting nurse, home health aide, or nurse's aide?

7.

YAMCNH Yes No Don't know Refused

YAMCVN Yes No Don't know Refused

Page 2

)

Proxy Interview

1

2

3

4

8

7

1 0 8 7

YABEDDAY

1 0 8 7

YACUTDAY

1 0 8 7

7801

Page Link #

Now I'm going to ask you about some medical problems that (name of Health ABC participant)might have had in the past 12 months.


8.

YAHCHBP Yes No Don't know Refused

Diabetes or sugar diabetes? Again, we are specifically interested in hearing about diabetes that wasdiagnosed for the first time in the past 12 months.

9.

YASGDIAB Yes No Don't know Refused

In the past 12 months, has (name of Health ABC participant) fallen and landed on the floor or ground?

How many times has (he/she) fallen in the past 12 months?If you are unsure, please make your best guess.

10.

Please go to Question #11

YAAJFALL Yes No Don't know Refused

YAAJFNUMOne

Two or three

Four or five

Six or more

Don't know

Page 3

In the past 12 months, was (name of Health ABC participant) told by a doctorthat (he/she) had...?

PROXY INTERVIEW

Proxy Interview

1 0 8 7

1 0 8 7

1 0 8 7

1

2

4

6

8

Page Link #

Now I'm going to ask about some medical problems (name of Health ABC participant) might have hadsince we last spoke to (him/her) about 6 months ago, which was on

Since we last spoke to (name of Health ABC participant) about 6 months ago, was (he/she)told by a doctor that (he/she) had a heart attack, angina, or chest pain due to heart disease?

YAHCHAMI Yes No Don't know Refused

Since we last spoke to (name of Health ABC participant) about 6 months ago, was (he/she)told by a doctor that (he/she) had a stroke, mini-stroke, or TIA?

YAHCCVAYes No Don't know Refused

Page 4

Was (he/she) hospitalized overnight for this problem?

Complete a Health ABC Event Form,Section I, for each overnight hospitalization.Record reference #'s below:

a.

b.

c.YAREF11C

YAREF11B

YAREF11A

11.

12.

YAHOSMIYes No

13. Since we last spoke to (name of Health ABC participant) about 6 months ago, was (he/she)told by a doctor that (he/she) had congestive heart failure?

YACHF Yes No Don't know Refused

Go to Question #12



a.

b.

c.YAREF12C

YAREF12B

YAREF12A

Go to Question #13



a.

b.

c.YAREF13C

YAREF13B

YAREF13A

Go to Question #14

YAHOSMI2Yes No

YAHOSMI3Yes No

PROXY INTERVIEW

YearDayMonth

Proxy Interview

1 0 8 7

1 0 8 7

10 8 7

1 0

01

1 0

Page Link #

Since we last spoke to (name of Health ABC participant) about 6 months ago, was (he/she)told by a doctor that (he/she) had cancer? We are specifically interested in hearing about acancer that was diagnosed for the first time since we last spoke to (him/her).

YACHMGMTYes No Don't know Refused

Page 5

YAREF14C

YAREF14B

YAREF14A

Since we last spoke to (name of Health ABC participant) about 6 months ago, was (he/she)told by a doctor that (he/she) had pneumonia?

YALCPNEUYes No Don't know Refused

Complete a Health ABC Event Form,Section II, for each event.Record reference #'s below:

YAREF15C

YAREF15B

YAREF15A

Since we last spoke to (name of Health ABC participant) about 6 months ago, was (he/she)told by a doctor that (he/she) broke or fractured a bone(s)?

YAOSBR45Yes No Don't know Refused

YAREF16C

YAREF16B

YAREF16A



14.

15.

16.

PROXY INTERVIEW

Proxy Interview

a.

b.

c.

a.

b.

c.

a.

b.

c.

1 0 8 7

1 0 8 7

1 0 8 7

Page Link #

Was (name of Health ABC participant) hospitalized overnight for any other reasons since we last spoketo (him/her) about 6 months ago?

YAHOSPYes No Don't know Refused

Has (name of Health ABC participant) had any same day outpatient surgery since we lastspoke to (him/her) about 6 months ago?

YAOUTPAYes No Don't know Refused


YABLART

Yes

No

Don't know


Cataract surgery


a.

b.

c.

d.

Page 6

a. b. c.YAREF17B

YAREF17D

YAREF17A


YAREF17E

YAREF17C

YAREF17Fd. e. f.



17.

18.


YAGALLBL

Yes

No

Don't know

YACATAR

Yes

No

Don't know

YATURP

Yes

No

Don't know

YAREF18A

Reference #

PROXY INTERVIEW

Proxy Interview

1 0 8 7

1 0 8 7

1

0

8

0

1

8

0

1

8

0

1

8

Page Link #

19. Is there any other illness or condition for which (name of Health ABC participant) sees adoctor or other health care professional?



YAOTILLYes No Don't know Refused

Page 7

20. Does (name of Health ABC participant) have any problems with (his/her) memory?


YAMEMYes No Don't know Refused

Did (his/her) trouble with memory begin suddenly or slowly?YAMEMBEGSuddenly

Slowly

Don't know

a.

b. Has the course of memory problems been a steady downhill progression,an abrupt decline, stayed the same, or gotten better?

YAMEMPRGSteady downhill progression

Abrupt decline

Stayed the same (no decline)

Gotten better

Don't know

c. Is a doctor aware of (his/her) memory problems?

YAMEMDRYes No Don't know

What does the doctor believe is causing (his/her) memory problems?(Interviewer Note: Please mark only one answer.)

YAMEMPRBAlzheimer's disease

Confusion

Delerium

Dementia

Depression

Multiinfarct

Parkinson's disease

Stroke

Nothing wrong

Other

Don't know

(Please specify)

PROXY INTERVIEW

Proxy Interview

1 0 8 7

1 0 8 7

1 0 8

1

28

1

2

3

4

8

1

2

3

4

56

7

9

10

11

8

Page Link #

21. Because of a health or physical problem, does (name of Health ABC participant) have anydifficulty walking a quarter of a mile, that is about 2 or 3 blocks?(Interviewer Note: If the proxy responds "Doesn't do," probe to determine whether thiswas because of a health or physical problem. If the participant doesn't walk because ofa health or physical problem, mark "Yes." If the participant doesn't walk for otherreasons, mark "Does not do.")

How much difficulty does (he/she) have?(Interviewer Note: Read response options.)

YADWQMDFA little difficulty

Some difficulty

A lot of difficulty

Or are they unable to do it?

Don't know

Go to Question #22

22.

Go to Question #23

Because of a health or physical problem, does (name of Health ABC participant) have anydifficulty walking up 10 steps, that is about 1 flight, without resting?(Interviewer Note: If the proxy responds "Doesn't do," probe to determine whether this isbecause of a health or physical problem. If the participant doesn't walk up 10 stepsbecause of a health or physical problem, mark "Yes." If the participant doesn't walk upsteps for other reasons, such as there are simply no steps in the area, mark "Does not do.")


YADIFA little difficulty

Some difficulty

A lot of difficulty


Don't know

YADW10YN Yes No Don't know Refused Does not do

YADWQMYN Yes No Don't know Refused Does not do

PROXY INTERVIEW

Proxy Interview

1 0 8 7 9

1 0 8 7 9

1

2

3

4

8

1

2

3

4

8

Page Link #

Does (name of Health ABC participant) have to use a cane, walker, crutches, or otherspecial equipment to help (him/her) get around?

25. Does (name of Health ABC participant) have any difficulty bathing or showering?

YABATHYNYes No Don't know Refused

24. Because of a health or physical problem, does (name of Health ABC participant) have any difficultygetting in and out of bed or chairs?

YADIOYNYes No Don't know Refused

YADIODIFA little difficulty

Some difficulty

A lot of difficulty


Don't know


YAEQUIPYes No Don't know Refused

a.

b. Does (he/she) usually receive help from anotherperson when (he/she) gets in and out of bed or chairs?

YADIORHYYes No Don't know

a. How much difficulty does (he/she) have?(Interviewer Note: Read response options.)

YABATHDFA little difficulty

Some difficulty

A lot of difficulty


Don't know

b. Does (he/she) usually receive help from anotherperson in bathing or showering?

YABATHRHYes No Don't know

PROXY INTERVIEW

Proxy Interview

1 0 8 7

7801

1

2

3

4

8

1

2

3

4

8

1 0 8

1 0 8

1 0 8 7

23.

Page Link #

In general, would you say that (name of Health ABC participant's) appetiteor desire to eat has been. . . ?(Interviewer Note: Read response options.)

YAAPPETVery good

Good

Moderate

Poor

Very poor

Don't know

Refused

27.

YACHN5LB Yes No Don't know Refused

Did (he/she) gain or lose weight?(Interviewer Note: We are interested in net gain or loss during the past 6 months.)

YAGNLSGain Lose Don't know

How many pounds did (he/she) gain/lose in the past 6 months?(Interviewer Note: If necessary, probe - "If you are unsure, please make your best guess.")

pounds YAHOW6DNDon't know

a.

b.

28. Since we last spoke to (name of Health ABC participant) about 6 months ago, has (his/her)weight changed by 5 or more pounds?(Interviewer Note: We are interested in net gain or loss during the past 6 months.In other words, is the participant either 5 or more pounds heavier or lighter thanthey were 6 months ago?)

YADDYNYes No Don't know Refused

Does (name of Health ABC participant) have any difficulty dressing?26.


YADDDIFA little difficulty

Some difficulty

A lot of difficulty


Don't know

b. Does (he/she) usually receive help from anotherperson in dressing?

YADDRHYNYes No Don't know

PROXY INTERVIEW

Proxy Interview

7801

1

2

3

4

8

1 0 8 7

1 0 8

1

2

3

4

5

8

7

1 2 8

8YAHOW6

Page Link #

29. Where does (name of Health ABC participant) usually go for health care or adviceabout health care?(Interviewer Note: Read response options. Please mark only one answer.)

YAHCSRC





Emergency room


(Examples: Keystone, Cigna, UPMC Health Plan, Aetna, HealthAmerica, HealthSpring)(Please specify:

)

PROXY INTERVIEW

)

Proxy Interview

Examiner Note: Please update the name, address, and telephonenumber of the doctor or place that the participant usually goes to forhealth care on the HABC Participant Contact Information report.

1

2

3

4

5

6

Page Link #

30. We would like to update all of (name of Health ABC participant's) contact information this year.The address that we currently have listed for (name of Health ABC participant) is:(Interviewer Note: Please review the HABC Participant Contact Information report andconfirm that the address you have for the participant is correct.)


Page 12

The telephone number(s) that we currently have for (name of Health ABC participant) is (are)(Interviewer Note: Please review the HABC Participant Contact Information report andconfirm that the telephone number(s) that you have for the participant are correct.)

Please tell me if these telephone numbers are correct.

PROXY INTERVIEW

Proxy Interview

NOT COLLECTEDYes No

Examiner Note: Please record the street address, city, state and zip code forthe participant on the HABC Participant Contact Information report.


Examiner Note: Please record the telephone number(s) for the participanton the HABC Participant Contact Information report.

Are the telephone number(s) that we currently have correct?

NOT COLLECTEDYes No

Page Link #

Do you expect (name of Health ABC participant) to move or have a different mailing addressin the next 6 months?

Page 13

31.

PROXY INTERVIEW

Proxy Interview

YAMOVEYes No Don't know Refused

Examiner Note: Please record the new mailing address and telephone number, anddate the new address and telephone numbers are effective on the HABC ParticipantContact Information report.

7801

Page Link #

Interviewer Note: Please answer the following question based on your judgment of theproxy's responses to the Proxy Interview.

On the whole, how reliable do you think the proxy's responses to the Proxy Interview are?

YARELY

Very reliable

Fairly reliable

Not very reliable

Don't know

32.

Page 14

PROXY INTERVIEW

What is the primary reason a proxy was contacted for the Semi-Annual Telephone Interview orAnnual Contact? Please mark only one reason.

YAPROXY

Illness/health problem(s)

Hearing difficulties

Cognitive difficulties

In nursing home/long-term care facility

Refused to give reason


33.

Thank you very much for answering these questions. Please remember to call us if(name of Health ABC participant) is admitted to a hospital or nursing home for any reasonso that we can better understand changes in (his/her) health. We would also like to hearfrom you if (name of Health ABC participant) moves or if (his/her) mailing address changes.We will be calling you in about 6 months from now to find out how (name of Health ABCparticipant) has been doing.

Proxy Interview

)

1

2

3

8

1

2

3

4

5

6

Page Link #

YAPROXOT

HABCID

H


ACROS

Date Visit Completed Staff ID #

G1INSTID

SEMI-ANNUAL INTERVIEW

G1DATE

/ /YearDayMonth

Year of Semi-Annual Interview:

Semi-Annual InterviewVersion 8.0, 12/14/09

G1

Page 1

What is your...?

First Name Last NameM.I.

G1FNM

G1CONTAC13.5 14.5 15.5 16.527 29 31 33

G1LNM

In general, how would you say your health is? Would you say it is. . .

G2HSTAT

Excellent

Very good

Good

Fair

Poor

Don't know

Refused

Page 2

(Examiner Note: Read response options.)


(Examiner Note: Refer to Data from Prior Visits Report. Please also record this date onthe top of page 21. If participant agrees to only partial interview, ask questions first.)

NOT COLLECTED

/ /Month Day Year

G2BED12Yes No Don't know Refused

About how many days did you stay in bed all or most of the day because of an illness or injury?Please include days that you were a patient in a hospital.(Examiner Note: If necessary, probe - "If you are unsure, please make your best guess.")

days

G2CUT12Yes No Don't know Refused

How many days did you cut down on the things you usually do because of illness or injury?Please include days in bed.(Examiner Note: If necessary, probe - "If you are unsure, please make your best guess.")

days

1.

2.

3.

YEAR 13.5 INTERVIEWHABCID

HACROS

AcrosticHABC Enrollment ID #

= Priority questions

Since we last spoke to you about [# months since last contact] months ago, did you stay in bed all ormost of the day because of an illness or injury? Please include days that you were a patient in a hospital.

Since we last spoke to you about [# months since last contact] months ago, did you cut down on the thingsyou usually do, such as going to work or working around the house, because of an illness or injury?Please include days in bed.

Year of Interview

CONTAC13.5 14.5 15.5 16.5

Semi-Annual InterviewG2

I would like to ask you some questions that we asked you about 6 months ago, on (date of last contact).The reason for asking them again is to find out how you've been doing during the past six months.

1

2

3

4

5

8

7

G2BEDDAY

G2CUTDAY

1 0 8 7

1 0 8 7

MEDICAL STATUS

G3MCNHYes No Don't know Refused

G3MCVNYes No Don't know Refused

4.

5.

HABCID

HACROS

Acrostic Year of InterviewHABC Enrollment ID #

Since we last spoke to you about [# months since last contact] months ago,did you stay overnight as a patient in a nursing home or rehabilitation center?

Since we last spoke to you about [# months since last contact] months ago, did you receivecare at home from a visiting nurse, home health aide, or nurse's aide?

CONTAC13.5 14.5 15.5 16.5


1 0 8 7

1 0 8 7

G4MNRS

Arthritis

Back pain


Cancer



Diabetes


Fall

Foot/ankle pain

Heart disease


Hip fracture

Injury

Joint pain

Leg pain

Lung disease

Old age

Osteoporosis

Shortness of breath

Stroke

Other symptom


Don't know

Because of a health or physical problem, do you have any difficulty walking a quarter of a mile,that is about 2 or 3 blocks?(Examiner Note: If the participant responds "Don't do," probe to determine whether this is becauseof a health or physical problem. If the participant doesn't walk because of a health or physicalproblem, mark "Yes." If the participant doesn't walk for other reasons, mark "Don't do.")

G4DWQMYN Yes No Don't know Refused Don't do

How much difficulty do you have?(Examiner Note: Read response options.)G4DWQMDF


What is the main reason that you have difficulty? Is it because of arthritis, shortness of breath,heart disease, or some other reason?(Examiner Note: Do NOT read response options. If "some other reason," probe forresponse. Mark only ONE answer.)

(including angina, congestive heart failure, etc)



(Please specify: )


Go to Question #6d

a.

b.

(Please specify: )

Go to Question #7

PHYSICAL FUNCTION

c. Do you have any difficulty walking across a small room?

G4DWSMRMYes No Don't know Refused

Go to Question #7Page 4

6.

HABCID

HACROS


CONTAC13.5 14.5 15.5 16.5


1 0 8 7 9

1 2 3 4 8

1

2

3

4

5

6

7

8

9

23

10

11

12

13

14

24

15

16

17

18

19

20

21

22

1 0 8 7

How easy is it for you to walk a quarter of a mile?(Examiner Note: Read response options.)

G5DWQMEZ

Very easy

Somewhat easy

Or not that easy

Don't know/don't do

Because of a health or physical problem, do you have any difficulty walking a distance ofone mile, that is about 8 to 12 blocks?

G5DW1MYN

Yes

No

Don't know/don't do

How easy is it for you to walk one mile?(Examiner Note: Read response options.)

G5DW1MEZ

Very easy

Somewhat easy

Or not that easy

Don't know/don't do

6d.

6e.

6f.

Go to Question #7

Go to Question #6f

Go to Question #6f

PHYSICAL FUNCTIONHABCID

HACROS

AcrosticHABC Enrollment ID # Year of Interview

CONTAC13.5 14.5 15.5 16.5


1

2

3

8

1

0

8

1

2

3

8

Go to Question #7c

Because of a health or physical problem, do you have any difficulty walking up 10 steps,that is about 1 flight, without resting?(Examiner Note: If the participant responds "Don't do," probe to determine whether this isbecause of a health or physical problem. If the participant doesn't walk up 10 steps because ofa health or physical problem, mark "Yes." If the participant doesn't walk up steps for otherreasons, such as there are simply no steps in the area, mark "Don't do.")

How much difficulty do you have?(Examiner Note: Read response options.)G6DIF


What is the main reason that you have difficulty? Is it because of arthritis, shortness of breath,heart disease, or some other reason?(Examiner Note: Do NOT read response options. If "some other reason,"probe for response. Mark only ONE answer.)

a.

b.

G6DW10YN Yes No Don't know Refused Don't do

Go to Question #8

Go to Question #8

PHYSICAL FUNCTION

Page 6

Arthritis

Back pain


Cancer



Diabetes


Fall

Foot/ankle pain

Heart disease


Hip fracture

Injury

Joint pain

Leg pain

Lung disease

Old age

Osteoporosis

Shortness of breath

Stroke

Other symptom


Don't know(including angina, congestive heart failure, etc)



(Please specify: )


(Please specify: )

7.

HABCID

HACROS

AcrosticHABC Enrollment ID # Year of Interview

CONTAC13.5 14.5 15.5 16.5


1 0 8 7 9

1 2 3 4 8

1

2

3

4

5

6

7

8

9

23

10

11

12

13

14

24

15

16

17

18

19

20

21

22

G6MNRS2

7c.

7d.

7e.


G7DW10EZ

Very easy

Somewhat easy

Or not that easy

Don't know/don't do

Because of a health or physical problem, do you have any difficulty walking up 20 steps,that is about 2 flights, without resting?

G7DW20YN Yes

No

Don't know/don't do


G7DW20EZ

Very easy

Somewhat easy

Or not that easy

Don't know/don't do

Go to Question #8

Go to Question #7e

PHYSICAL FUNCTION

Go to Question #7e

Page 7

HABCID

HACROS


CONTAC13.5 14.5 15.5 16.5


1

2

3

8

1

0

8

1

2

3

8

PHYSICAL FUNCTIONHABCID

HACROS


Do you have any difficulty doing heavy work around the house like vacuuming, shoveling snow, mowingor raking the lawn, gardening, or scrubbing windows, walls or floors?(Examiner Note: If a participant responds, "I can do them but my doctor says I'm not allowed,"or "I could do them but I chose not to do them," probe by re-asking the stem question aboutwhether they would have any difficulty doing heavy work around the house. If the participantresponds, "No," check "No" and ask the follow-up question.)

8.

G8DIFHW Yes No Don't know Refused


G8EZHW

Very easy

Somewhat easy

Or not that easy

Don't know

How easy is it for you to do heavy work around thehouse?(Examiner Note: Read response options.)

G8DHWAMT

A little difficulty

Some difficulty

A lot of difficulty

Or are you unable

Don't know

CONTAC13.5 14.5 15.5 16.5


1 0 8 7

1

2

3

4

8

1

2

3

8

Do you have to use a cane, walker, crutches, or other special equipment to help you get around?

Do you have any difficulty bathing or showering?

Does someone usually help you bathe or shower?

G9BATHRHYes No Don't know

G9BATHYNYes No Don't know Refused

Because of a health or physical problem, do you have any difficulty getting in and out of bed or chairs?G9DIOYNYes No Don't know Refused

Does someone usually help you get in and out of bed or chairs?

G9DIORHYYes No Don't know

Do you have any difficulty dressing?

Does someone usually help you to dress?

G9DDYNYes No Don't know Refused

G9EQUIPYes No Don't know Refused

PHYSICAL FUNCTION

Because of a health or physical problem, do you have any difficulty standing up from a chairwithout using your arms?


G9DSTAMT

A little difficulty

Some difficulty

A lot of difficulty


Don't know

How easy is it for you to stand up from a chair withoutusing your arms?(Examiner Note: Read response options.)

G9EZSTA

Very easy

Somewhat easy

Or not that easy

Don't know

G9DIFSTAYes No Don't know Refused

G9DDRHYNYes No Don't know

Page 9

9.

10.

11.

12.

13.

HABCID

HACROS


CONTAC13.5 14.5 15.5 16.5


1 0 8 7

1 0 8 7

1 0 8

1 0 8 7

1 0 8

1 0 8 7

1 0 8

1 0 8 7

1

2

3

4

8

1

2

3

8

Do you have any difficulty stooping, crouching or kneeling?(Examiner Note: "Difficulty" refers to difficulty getting down AND/OR getting back up.)

GEDSCKAM

A little difficulty

Some difficulty

A lot of difficulty


Don't know


PHYSICAL FUNCTION

GEDIFSCK Yes No Don't know Refused

Do you have any difficulty raising your arms up over your head?

Do you have any difficulty using your fingers to grasp or handle?


GEDIFARM Yes No Don't know Refused

GEDARMAM

A little difficulty

Some difficulty

A lot of difficulty


Don't know


GEDIFFN Yes No Don't know Refused

GEDIFNAM

A little difficulty

Some difficulty

A lot of difficulty


Don't know

Page 10

14.

15.

16.

HABCID

HACROS


CONTAC13.5 14.5 15.5 16.5

Semi-Annual InterviewGE

1 0 8 7

1

2

3

4

8

1 0 8 7

1

2

3

4

8

1 0 8 7

1

2

3

4

8

Because of a health or physical problem, do you have any difficulty lifting or carrying somethingweighing 10 pounds, for example a small bag of groceries or an infant?

How much difficulty do you have?(Examiner Note:Read response options.)


GFD10AMT

A little difficulty

Some difficulty

A lot of difficulty

Or are you unable

Don't know

GFEZ10LB

Very easy

Somewhat easy

Or not that easy

Don't know

Do you have any difficulty lifting or carrying somethingweighing 20 pounds, for example, a large full bag ofgroceries?


GFEZ20LB

Very easy

Somewhat easy

Or not that easy

Don't know

to do it

Go to Question #18

GFDIF10 Yes No Don't know Refused

GFD20LBSYes No Don't know

Page 11

17.

PHYSICAL FUNCTION

HABCID

HACROS


CONTAC13.5 14.5 15.5 16.5

Semi-Annual InterviewGF

1 0 8 7

1

2

3

4

8

1

2

3

8

1 0 8

1

2

3

8

Did you do heavy or major chores like scrubbing windows or walls, vacuuming, orcleaning gutters; home maintenance activities like painting; gardening or yardwork;or anything like these activities, at least 10 times, in the past 12 months?

a. In the past 7 days, did you do heavy chores or home maintenance activities?

Go to Question #19

Go to Question #19

b. About how much time did you spend doing heavy chores or homemaintenance activities in the past 7 days (not counting rest periods)?(Examiner Note: If less than 1 hour, record number of minutes.)

GGHC12MOYes No Don't know Refused

GGHCHRS GGHCMINS

Hours MinutesGGHCDKDon't know

GGHC7DAYYes No Don't know


Page 12

18.

HABCID

HACROS


CONTAC13.5 14.5 15.5 16.5

Semi-Annual InterviewGG

1 0 8 7

1 0 8

-1

Did you walk for exercise, or walk to work, the store, or church, or walk the dog,at least 10 times, in the past 12 months?

In the past 7 days, did you go walking?

Go to Question #20

What is the main reason you didnot go walking in the past 7 days?

GHEWREAS

Bad weather

Not enough time

Injury

Health problems

Lost interest

Felt unsafe

Not necessary

Other

Don't know

How many times did you go walking in the past 7 days?

timesAbout how much time, on average, did you spendwalking each time you walked (excluding rest periods)?(Examiner Note: If less than 1 hour, record numberof minutes.)

When you walk, do you usually walk at a brisk pace(as fast as you can), a moderate pace, or at a leisurelystroll?

GHEWPACEBrisk Moderate Stroll Don't know

GHEW7DAYYes No

GHEW12MOYes No Don't know Refused

a.

b.

c.

GHEWHRS

GHEWMINS

Hours Minutes

GHEWTMDKDon't know

GHEWTDKDon't know


Page 13

Did you walk up a flight of stairs (a flight is about 10 steps), at least 10 times, in the past 12 months?

a. In the past 7 days, did you walk up a flight of stairs?

b. About how many flights did you walk up in the past 7 days?If you are unsure, please make your best guess.

flights

About how many of these flights did you walk up carrying a small loadlike laundry, groceries, or an infant?

c.

flights

Go to Question #21

Go to Question #21

GHFS12MOYes No Don't know Refused

GHFSNUMDDon't know

GHFSLODKDon't know

GHFS7DAYYes No Don't know

19.

20.

HABCID

HACROS


CONTAC13.5 14.5 15.5 16.5

Semi-Annual InterviewGH

1 0 8 7

1 0

-1

-1

1 2 3 8

1

2

3

4

5

6

7

8

9

1 0 8 7

1 0 8

-1

-1

GHEWTIME

GHFSNUM

GHFSLOAD

Did you do any high intensity exercise, such as bicycling, swimming, jogging, racquetsports or using a stair-stepping, rowing or cross country ski machine or exercycle,at least 10 times, in the past 12 months?

In the past 7 days, did you do high intensity exercise?

Go to Question #22

GJHI7DAY Yes No

GJHINDEX

Bad weather

Not enough time

Injury

Health problems

Lost interest

Felt unsafe

Not necessary

Other

Don't know

What is the main reason you have not done anyhigh intensity exercise in the past 7 days?


GJHIABEBicycling/exercycle

GJHIASWMSwimming

GJHIAJOGJogging

GJHIAAERAerobics

GJHIARSRacquet sports

GJHIAROWRowing machine

GJHIASKICross country ski machine

GJHIAOTHOther

GJHIASSStair-stepping

In the past 7 days, about how much time didyou spend doing (first activity named byparticipant)?(Examiner Note: If less than 1 hour,record number of minutes.)

Mark all that apply.)

GJHI12MOYes No Don't know Refused


a.

b.

(Please specify):

GJH

IA1H

R

GJH

IA1M

N

Hours Minutes GJHIA1DKDon't know

Page 14

21.

HABCID

HACROS


CONTAC13.5 14.5 15.5 16.5

Semi-Annual InterviewGJ

1 0 8 7

1 0

-1

-1

-1-1

-1

-1

-1

-1

-1

1

2

3

4

5

6

7

8

9

-1

GKH1TIME

Did you do any moderate intensity exercise, such as golf, bowling, dancing, skating,bocce, table tennis, hunting, sailing or fishing, at least 10 times, in the past 12 months?

In the past 7 days, did you do moderate intensity exercise?

GKMI7DAY Yes No

What is the main reason you havenot done any moderate intensityexercise in the past 7 days?

GKMINDEX

Bad weather

Not enough time

Injury

Health problems

Lost interest

Felt unsafe

Not necessary

Other

Don't know


GKMIGOLFGolf

GKMIBOWLBowling

GKMIDANCDancing

GKMISKATSkating

GKMIBOCCBocce

GKMITENNTable tennis

GKMIOT1Other

GKMIPOOLBilliards/pool

GKMIHUNTHunting

GKMIBOATSailing/boating

GKMIFISHFishing

In the past 7 days, about how much time didyou spend doing (first activity named byparticipant)?(Examiner Note: If less than 1 hour, recordnumber of minutes.)

Mark all that apply.)

Go to Question #23

(Please specify):

GK

MIA

1HR

GK

MIA

1MN

Hours Minutes


GKMI12MO Yes No Don't know Refused

Page 15

GKMIA1DKDon't know

b.

a.

22.

HABCID

HACROS


CONTAC13.5 14.5 15.5 16.5

Semi-Annual InterviewGK

1 0 8 7

1 0

-1

-1

-1

-1

-1

-1

-1

-1

-1

-1

-1

1

2

3

4

5

6

7

8

9

-1

GKM1TIME

APPETITE AND WEIGHT CHANGE

In general, would you say that your appetite or desire to eat has been. . . ?(Examiner Note: Read response options.)

GLAPPET

Very good

Good

Moderate

Poor

Very poor

Don't know

Refused

Now I have some questions about your appetite.23.

GLTRYLS2 Yes No Don't know Refused

At the present time, are you trying to lose weight?27.

HABCID

HACROS


24. Because of a health or physical problem, do you have any difficulty preparing meals?

25. Because of a health or physical problem, do you have any difficulty shopping for food?

26. How much do you currently weigh?(Examiner Note: If necessary, probe - "If you are unsure, please make your best guess.")

pounds GLLBS2 Don't know/don't remember Refused

GLDFPREP Yes No Does not do Don't know Refused

GLDFSHOP Yes No Does not do Don't know Refused

CONTAC13.5 14.5 15.5 16.5

Semi-Annual InterviewGL

1

2

3

4

5

8

7

1 0 9 8 7

1 0 9 8 7

8 7

1 0 8 7

GLWTLBS

APPETITE AND WEIGHT CHANGEHABCID

HACROS


Since we last spoke to you about 6 months ago, has your weight changed by 5 or more pounds?(Examiner Note: We are interested in net gain or loss during the past 6 months.In other words, is the participant currently either 5 or more pounds heavier or lighterthan they were 6 months ago.)

GMCHN5LB Yes No Don't know Refused

GMTRGNLSYes No Don't know

Did you gain or lose weight?(Examiner Note: We are interested in net gain or loss during the past 6 months.)

a.

GMGNLSGain Lose Don't know/don't remember

How many pounds did you gain/lose in the past 6 months?(Examiner Note: If necessary, probe - "If you are unsure, please make your best guess.")

poundsGMHOW6DN

Don't know/don't remember Refused

b.

c. Were you trying to gain/lose weight?

28.

CONTAC13.5 14.5 15.5 16.5

Semi-Annual InterviewGM

1 0 8 7

1 2 8

801

78GMHOW6

29.

MEDICAL CONDITIONS

Now I'm going to ask you about some medical problems that you might have had in the past 12 months.


GNHCHBP Yes No Don't know Refused

Diabetes or sugar diabetes? Again, we are specifically interested in hearing aboutdiabetes that was diagnosed for the first time in the past 12 months.

GNSGDIAB Yes No Don't know Refused



Go to Page 19, Question #33

GNAJFALL Yes No Don't know Refused

GNAJFNUM

One

Two or three

Four or five

Six or more

Don't know

In the past 12 months, has a doctor told you that you had...?

30.

31.

Page 18

HABCID

HACROS


CONTAC13.5 14.5 15.5 16.5

Semi-Annual InterviewGN

1 0 8 7

1 0 8 7

1 0 8 7

1

2

4

6

8



Go to Question #33

GP6MFALLYes No Don't know Refused

GP6MFNUM

One

Two or three

Four or five

Six or more

Don't know

Page 19

HABCID

HACROS


i.

Were you injured in any of your falls?

GPINJFALYes No Don't know

ii.

Go to Question #33

iii. Did you seek medical treatment after any of your falls?GPTRTFALYes No Don't know

iv. Were you hospitalized after any of your falls?

GPHOSFALYes No Don't know

v. Have you been told by a doctor that you broke or fractured a bone(s)because of any of your falls?

GPBBNFALYes No Don't know

MEDICAL CONDITIONS

32.Now, please think about the past 6 months.

Are you troubled by shortness of breath when hurrying on a level surface or walking up a slight hill?33.

GPLCSBUPYes No Don't know Refused

Do you ever have to stop for breath when walking at your own pace on a level surface?

GPLCSBLSYes No Don't know Refused

34.

CONTAC13.5 14.5 15.5 16.5

Semi-Annual InterviewGP

1 0 8 7

1

2

4

6

8

1 0 8

1 0 8

1 0 8

1 0 8

1 0 8 7

1 0 8 7

Has a doctor ever told you that you had any of the following...?

Emphysema?

Chronic obstructive pulmonary disease or COPD?

a.

b.

c. Chronic bronchitis?

Do you still have chronic bronchitis?

GQLCSHCBYes No Don't know

GQLCEMPHYes No Don't know Refused

GQLCCOPDYes No Don't know Refused

GQLCCHBRYes No Don't know Refused

35.

MEDICAL CONDITIONSHABCID

HACROS


CONTAC13.5 14.5 15.5 16.5

Semi-Annual InterviewGQ

1 0 8 7

1 0 8 7

1 0 8 7

1 0 8

36.


Now I'm going to ask you about any medical problems you might have had since we last spoke to youabout [# months since last contact] months ago, which was on

GRHCHAMI Yes No Don't know Refused



a.

b.

c.GRHRTRFC

GRHRTRFB

GRHRTRFA

GRHOSMI Yes No

Go to Question #37

GRCHF Yes No Don't know Refused



a.

b.

c. GRCHFRFC

GRCHFRFB

GRCHFRFA

GRHOSMI3 Yes No

Go to Question #38

YearDayMonth

37.

Page 21

HABCID

HACROS


Since we last spoke to you about [# months since last contact] months ago,has a doctor told you that you had a heart attack, angina, or chest pain due to heart disease?

Since we last spoke to you about [# months since last contact] months ago,has a doctor told you that you had congestive heart failure?

CONTAC13.5 14.5 15.5 16.5

Semi-Annual InterviewGR

1 0 8 7

1 0

1 0 8 7

1 0

GSHCCVA Yes No Don't know Refused



a.

b.

c. GSTIARFC

GSTIARFB

GSTIARFA

GSHOSMI2 Yes No

Go to Question #39

38.


GSCHMGMT Yes No Don't know Refused

a.

b.

c.GSCANRFC

GSCANRFB

GSCANRFA


39.

HABCID

HACROS


Since we last spoke to you about [# months since last contact] months ago,has a doctor told you that you had a stroke, mini-stroke, or TIA ?

Since we last spoke to you about [# months since last contact] months ago, has a doctor told youthat you had cancer? We are specifically interested in hearing about a cancer that your doctordiagnosed for the first time since we last spoke to you.

CONTAC13.5 14.5 15.5 16.5

Semi-Annual InterviewGS

1 0 8 7

1 0

1 0 8 7

b.

GTLCPNEU Yes No Don't know Refused


a.

c.GTPNERFC

GTPNERFB

GTPNERFA


40.

GTOSBR45 Yes No Don't know Refused

a.

b.

c.GTFXREFC

GTFXREFB

GTFXREFA


41.

HABCID

HACROS


Since we last spoke to you about [# months since last contact] months ago,has a doctor told you that you had pneumonia?

Since we last spoke to you about [# months since last contact] months ago,have you been told by a doctor that you broke or fractured a bone(s)?

CONTAC13.5 14.5 15.5 16.5

Semi-Annual InterviewGT

1 0 8 7

1 0 8 7

MEDICAL CONDITIONS IN PAST 6 MONTHS42.

GUHOSP12Yes No Don't know Refused

GUOUTPAYes No Don't know Refused


GUBLART

Yes

No

Don't know


Cataract surgery


a.

b.

c.

d.

a. b. c.GUHSPRFB

GUHSPRFD

GUHSPRFA


GUHSPRFE

GUHSPRFC

GUHSPRFFd. e. f.




GUGALLBLYes

No

Don't know

GUCATARYes

No

Don't know

GUTURPYes

No

Don't know

GUOUTRFA

Reference #

43.

HABCID

HACROS


Were you hospitalized overnight for any other reasons since we last spoke to you about[# months since last contact] months ago?

Have you had any same day outpatient surgery since we last spoke to you about[# months since last contact] months ago?

CONTAC13.5 14.5 15.5 16.5

Semi-Annual InterviewGU

1 0 8 7

1 0 8 7

1

08

1

08

1

08

1

08

MEDICAL CONDITIONS AND FATIGUE


Is there any other illness or condition for which you see a doctor or other health care professional?

Go to Question #45

GVOTILLYes No Don't know Refused

44.

Please describe your usual energy level in the past month, where 0 is no energy and 10 isthe most energy that you have ever had.

Energy level GVELEVRFDon't know Refused

45.

HABCID

HACROS


46. In the past month, on the average, have you been feeling unusually tired during the day?

Have you been feeling unusually tired...?(Examiner Note: Read response options.)

GVELOFTN

All of the time

Most of the time

Some of the time

Don't know

Refused

GVELTIREYes No Don't know Refused

CONTAC13.5 14.5 15.5 16.5

Semi-Annual InterviewGV

1 0 8 7

1 0 8 7

1

2

3

8

7

8 7GVELEV

CURRENT ADDRESS AND TELEPHONE NUMBERHABCID

HACROS


47. Do you expect to move or have a different address in the next 6 months?

GWMOVEYes No Don't know Refused

Examiner Note: Please record the new mailing address and telephone number, anddate when the new address and telephone numbers are effective.

Thank you very much for answering these questions. I enjoyed talking with you. Pleaseremember to call us if you are admitted to a hospital or nursing home for any reason so thatwe can better understand changes in your health. We would also like to hear from you if youmove or if your mailing address changes.

CONTAC13.5 14.5 15.5 16.5

Semi-Annual InterviewGW

1 0 8 7

HABC Enrollment ID # Acrostic Date Form Completed Staff ID #

ACROS YASTFID

Page 1


YearDayMonth

Type of Contact:

YACONTAC

Home (face-to-face interview)

Clinic (face-to-face interview)

Nursing home (face-to-face interview)

Telephone interview


1.

=Semi-annualtelephone contactquestions

PROXY INTERVIEWHABCID

H

Page Link #

What is your relationship to (name of Health ABC participant)?

YAREL

Spouse or partner

Child

Family member (other than spouse or child)

Close friend

Health care provider

Other

Refused

(Please specify:

2. How often do you have contact with (him/her)?(Interviewer Note: Please mark only one answer.)

YACONFRQ

Live together

Daily

3 or more times a week

Less than 3 times a week

Don't know

Refused

Proxy Interview, Version 1.6, 6/30/08

Interviewer Note: Ask all questions for annual contact. Ask only questions during semi-annual telephone contact.

)

Year of Contact:

(Please specify:

Go to Question #4

(but does not live together)

YADATE

/ /YearDayMonth

YADATES

/ /

)

)

1

2

3

4

5

6

7

1

2

3

4

8

7

YALINK

YARELOTH

VISITYear 11Year 11.5Year 12Year 12.5Year 13


(Please specify )

Interviewer Note: This refersto the type of contact thePARTICIPANT would have had, notwhere the proxy was interviewed.

Since we last spoke to (name of Health ABC participant) about 6 months ago, did (he/she) stay inbed all or most of the day because of an illness or injury? Please include days that (he/she) was apatient in a hospital.

YABEDYes No Don't know Refused

About how many days did (he/she) stay in bed all or most of the day because of an illness or injury?Please include days that (he/she) was a patient in a hospital.(Interviewer Note: If necessary, probe - "If you are unsure, please make your best guess.")

days

Since we last spoke to (name of Health ABC participant) about 6 months ago, did (he/she)cut down on the things (he/she) usually did, such as going to work or working around the house,because of an illness or injury? Please include days in bed.

YACUT Yes No Don't know Refused

How many days did (he/she) cut down on the things (he/she) usually did because of illness or injury?Please include days in bed.(Interviewer Note: If necessary, probe - "If you are unsure, please make your best guess.")

days

4.

5.

3. What is the most frequent type of contact?

YACONTYP

Mostly in person

Mostly by phone

Both in person and by phone

Other

Don't know

Refused

(Please specify:

PROXY INTERVIEW

Since we last spoke to (name of Health ABC participant) about 6 months ago, did (he/she)stay overnight as a patient in a nursing home or rehabilitation center?

6.

Since we last spoke to (name of Health ABC participant) about 6 months ago, did (he/she)receive care at home from a visiting nurse, home health aide, or nurse's aide?

7.

YAMCNH Yes No Don't know Refused

YAMCVN Yes No Don't know Refused

Page 2

)

Proxy Interview

1

2

3

4

8

7

1 0 8 7

YABEDDAY

1 0 8 7

YACUTDAY

1 0 8 7

7801

Page Link #

Now I'm going to ask you about some medical problems that (name of Health ABC participant)might have had in the past 12 months.


8.

YAHCHBPYes No Don't know Refused

Diabetes or sugar diabetes? Again, we are specifically interested in hearing about diabetes that wasdiagnosed for the first time in the past 12 months.

9.

YASGDIABYes No Don't know Refused

In the past 12 months, has (name of Health ABC participant) fallen and landed on the floor or ground?

How many times has (he/she) fallen in the past 12 months?If you are unsure, please make your best guess.

10.


YAAJFALLYes No Don't know Refused

YAAJFNUMOne

Two or three

Four or five

Six or more

Don't know

Page 3

In the past 12 months, was (name of Health ABC participant) told by a doctorthat (he/she) had...?

PROXY INTERVIEW

Proxy Interview

Page Link #

Now I'm going to ask about some medical problems (name of Health ABC participant) might have hadsince we last spoke to (him/her) about 6 months ago, which was on

Since we last spoke to (name of Health ABC participant) about 6 months ago, was (he/she)told by a doctor that (he/she) had a heart attack, angina, or chest pain due to heart disease?

YAHCHAMI Yes No Don't know Refused

Since we last spoke to (name of Health ABC participant) about 6 months ago, was (he/she)told by a doctor that (he/she) had a stroke, mini-stroke, or TIA?

YAHCCVAYes No Don't know Refused

Page 4



a.

b.

c.YAREF11C

YAREF11B

YAREF11A

11.

12.

YAHOSMIYes No

13. Since we last spoke to (name of Health ABC participant) about 6 months ago, was (he/she)told by a doctor that (he/she) had congestive heart failure?

YACHF Yes No Don't know Refused

Go to Question #12



a.

b.

c.YAREF12C

YAREF12B

YAREF12A

Go to Question #13



a.

b.

c.YAREF13C

YAREF13B

YAREF13A

Go to Question #14

YAHOSMI2Yes No

YAHOSMI3Yes No

PROXY INTERVIEW

YearDayMonth

Proxy Interview

1 0 8 7

1 0 8 7

10 8 7

1 0

01

1 0

Page Link #

Since we last spoke to (name of Health ABC participant) about 6 months ago, was (he/she)told by a doctor that (he/she) had cancer? We are specifically interested in hearing about acancer that was diagnosed for the first time since we last spoke to (him/her).

YACHMGMTYes No Don't know Refused

Page 5

YAREF14C

YAREF14B

YAREF14A

Since we last spoke to (name of Health ABC participant) about 6 months ago, was (he/she)told by a doctor that (he/she) had pneumonia?

YALCPNEUYes No Don't know Refused


YAREF15C

YAREF15B

YAREF15A

Since we last spoke to (name of Health ABC participant) about 6 months ago, was (he/she)told by a doctor that (he/she) broke or fractured a bone(s)?

YAOSBR45Yes No Don't know Refused

YAREF16C

YAREF16B

YAREF16A



14.

15.

16.

PROXY INTERVIEW

Proxy Interview

a.

b.

c.

a.

b.

c.

a.

b.

c.

1 0 8 7

1 0 8 7

1 0 8 7

Page Link #

Was (name of Health ABC participant) hospitalized overnight for any other reasons since we last spoketo (him/her) about 6 months ago?

YAHOSPYes No Don't know Refused

Has (name of Health ABC participant) had any same day outpatient surgery since we lastspoke to (him/her) about 6 months ago?

YAOUTPAYes No Don't know Refused


YABLART

Yes

No

Don't know


Cataract surgery


a.

b.

c.

d.

Page 6

a. b. c.YAREF17B

YAREF17D

YAREF17A


YAREF17E

YAREF17C

YAREF17Fd. e. f.



17.

18.


YAGALLBL

Yes

No

Don't know

YACATAR

Yes

No

Don't know

YATURP

Yes

No

Don't know

YAREF18A

Reference #

PROXY INTERVIEW

Proxy Interview

1 0 8 7

1 0 8 7

1

0

8

0

1

8

0

1

8

0

1

8

Page Link #

19. Is there any other illness or condition for which (name of Health ABC participant) sees adoctor or other health care professional?



YAOTILLYes No Don't know Refused

Page 7

20. Does (name of Health ABC participant) have any problems with (his/her) memory?


YAMEMYes No Don't know Refused

Did (his/her) trouble with memory begin suddenly or slowly?YAMEMBEGSuddenly

Slowly

Don't know

a.

b. Has the course of memory problems been a steady downhill progression,an abrupt decline, stayed the same, or gotten better?

YAMEMPRGSteady downhill progression

Abrupt decline

Stayed the same (no decline)

Gotten better

Don't know

c. Is a doctor aware of (his/her) memory problems?

YAMEMDRYes No Don't know

What does the doctor believe is causing (his/her) memory problems?(Interviewer Note: Please mark only one answer.)

YAMEMPRBAlzheimer's disease

Confusion

Delerium

Dementia

Depression

Multiinfarct

Parkinson's disease

Stroke

Nothing wrong

Other

Don't know

(Please specify)

PROXY INTERVIEW

Proxy Interview

Page Link #

21. Because of a health or physical problem, does (name of Health ABC participant) have anydifficulty walking a quarter of a mile, that is about 2 or 3 blocks?(Interviewer Note: If the proxy responds "Doesn't do," probe to determine whether thiswas because of a health or physical problem. If the participant doesn't walk because ofa health or physical problem, mark "Yes." If the participant doesn't walk for otherreasons, mark "Does not do.")


YADWQMDFA little difficulty

Some difficulty

A lot of difficulty


Don't know

Go to Question #22

22.

Go to Question #23

Because of a health or physical problem, does (name of Health ABC participant) have anydifficulty walking up 10 steps, that is about 1 flight, without resting?(Interviewer Note: If the proxy responds "Doesn't do," probe to determine whether this isbecause of a health or physical problem. If the participant doesn't walk up 10 stepsbecause of a health or physical problem, mark "Yes." If the participant doesn't walk upsteps for other reasons, such as there are simply no steps in the area, mark "Does not do.")


YADIFA little difficulty

Some difficulty

A lot of difficulty


Don't know

YADW10YN Yes No Don't know Refused Does not do

YADWQMYN Yes No Don't know Refused Does not do

PROXY INTERVIEW

Proxy Interview

1 0 8 7 9

1 0 8 7 9

1

2

3

4

8

1

2

3

4

8

Page Link #

Does (name of Health ABC participant) have to use a cane, walker, crutches, or otherspecial equipment to help (him/her) get around?

25. Does (name of Health ABC participant) have any difficulty bathing or showering?

YABATHYNYes No Don't know Refused

24. Because of a health or physical problem, does (name of Health ABC participant) have any difficultygetting in and out of bed or chairs?

YADIOYNYes No Don't know Refused

YADIODIFA little difficulty

Some difficulty

A lot of difficulty


Don't know


YAEQUIPYes No Don't know Refused

a.

b. Does (he/she) usually receive help from anotherperson when (he/she) gets in and out of bed or chairs?

YADIORHYYes No Don't know


YABATHDFA little difficulty

Some difficulty

A lot of difficulty


Don't know

b. Does (he/she) usually receive help from anotherperson in bathing or showering?

YABATHRHYes No Don't know

PROXY INTERVIEW

Proxy Interview

1 0 8 7

23.

Page Link #

In general, would you say that (name of Health ABC participant's) appetiteor desire to eat has been. . . ?(Interviewer Note: Read response options.)

YAAPPETVery good

Good

Moderate

Poor

Very poor

Don't know

Refused

27.

YACHN5LB Yes No Don't know Refused

Did (he/she) gain or lose weight?(Interviewer Note: We are interested in net gain or loss during the past 6 months.)

YAGNLSGain Lose Don't know

How many pounds did (he/she) gain/lose in the past 6 months?(Interviewer Note: If necessary, probe - "If you are unsure, please make your best guess.")

pounds YAHOW6DNDon't know

a.

b.

28. Since we last spoke to (name of Health ABC participant) about 6 months ago, has (his/her)weight changed by 5 or more pounds?(Interviewer Note: We are interested in net gain or loss during the past 6 months.In other words, is the participant either 5 or more pounds heavier or lighter thanthey were 6 months ago?)

YADDYNYes No Don't know Refused

Does (name of Health ABC participant) have any difficulty dressing?26.


YADDDIFA little difficulty

Some difficulty

A lot of difficulty


Don't know

b. Does (he/she) usually receive help from anotherperson in dressing?

YADDRHYNYes No Don't know

PROXY INTERVIEW

Proxy Interview

7801

1

2

3

4

5

8

7

1 2 8

8YAHOW6

Page Link #

29. Where does (name of Health ABC participant) usually go for health care or adviceabout health care?(Interviewer Note: Read response options. Please mark only one answer.)

YAHCSRC





Emergency room


(Examples: Keystone, Cigna, UPMC Health Plan, Aetna, HealthAmerica, HealthSpring)(Please specify:

)

PROXY INTERVIEW

)

Proxy Interview

Examiner Note: Please update the name, address, and telephonenumber of the doctor or place that the participant usually goes to forhealth care on the HABC Participant Contact Information report.

Page Link #

30. We would like to update all of (name of Health ABC participant's) contact information this year.The address that we currently have listed for (name of Health ABC participant) is:(Interviewer Note: Please review the HABC Participant Contact Information report andconfirm that the address you have for the participant is correct.)


Page 12

The telephone number(s) that we currently have for (name of Health ABC participant) is (are)(Interviewer Note: Please review the HABC Participant Contact Information report andconfirm that the telephone number(s) that you have for the participant are correct.)

Please tell me if these telephone numbers are correct.

PROXY INTERVIEW

Proxy Interview

NOT COLLECTEDYes No

Examiner Note: Please record the street address, city, state and zip code forthe participant on the HABC Participant Contact Information report.


Examiner Note: Please record the telephone number(s) for the participanton the HABC Participant Contact Information report.

Are the telephone number(s) that we currently have correct?

NOT COLLECTEDYes No

Page Link #

Do you expect (name of Health ABC participant) to move or have a different mailing addressin the next 6 months?

Page 13

31.

PROXY INTERVIEW

Proxy Interview

YAMOVEYes No Don't know Refused

Examiner Note: Please record the new mailing address and telephone number, anddate the new address and telephone numbers are effective on the HABC ParticipantContact Information report.

Page Link #

Interviewer Note: Please answer the following question based on your judgment of theproxy's responses to the Proxy Interview.

On the whole, how reliable do you think the proxy's responses to the Proxy Interview are?

YARELY

Very reliable

Fairly reliable

Not very reliable

Don't know

32.

Page 14

PROXY INTERVIEW

What is the primary reason a proxy was contacted for the Semi-Annual Telephone Interview orAnnual Contact? Please mark only one reason.

YAPROXY







33.

Thank you very much for answering these questions. Please remember to call us if(name of Health ABC participant) is admitted to a hospital or nursing home for any reasonso that we can better understand changes in (his/her) health. We would also like to hearfrom you if (name of Health ABC participant) moves or if (his/her) mailing address changes.We will be calling you in about 6 months from now to find out how (name of Health ABCparticipant) has been doing.

Proxy Interview

)

1

2

3

8

1

2

3

4

5

6

Page Link #

YAPROXOT

MISSED FOLLOW-UP CONTACTCONTACTComplete this form for each regularly scheduled follow-up clinic visit ortelephone contact that has been missed and cannot be made-up.

Type of Missed Follow-up Contact

Reason for Missed Follow-up Contact

Please check the primary reason for the missed follow-up visit or telephone contact.Check only one reason.





Too busy; time and/or work conflict

Caregiving responsibilities

Physician's advice

Family member's advice

Clinic too far/travel time

Moved out of area

Travelling/on vacation

Personal problem(s)

Unable to contact/unable to locate


Modified follow-up regimen

Withdrew from study/withdrew informed consent

Deceased

Other (Please specify: )

Version 4.0, 1/18/08

(e.g. will only agree to one contact per year)

Comments


ACROS

Date Form Completed Staff ID #

BJSTFIDHABCID

H

BJREASON

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

18

16

17

BJDATE

/ /Month Day Year

BJVISITYear 11Year 11.5Year 12Year 12.5Year 13


(Please specify )

BJID2

annual telephone interview - health abcannual telephone interview since we last spoke to you about...

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